Transcript Across The Lifecycle: Women’s Mental Health

D. Wolocko, Daily News
By
Ricardo J. Fernandez, M.D., DFAPA
Councilor, NJ Psychiatric Association
“Postpartum Depression”
Psychiatric Syndromes
of the
Postpartum Period
This presentation is for
the exclusive use of the
New Jersey Psychiatric
Association website
and for the purposes of consumer
information and education.
It may not be otherwise
reproduced or presented without
the knowledge and consent of
Ricardo J. Fernandez, M.D.
Women are at serious risk
for developing a
psychiatric illness after
childbirth.
D. Wolocko, Daily News
Postpartum mothers are at
significant risk of developing a
psychiatric illness severe
enough to require
hospitalization as the next
slide demonstrates.
This increased risk lasts for
about two years after
childbirth.
Admissions to a Psychiatric Hospital:
2 Years Pre and Post Delivery
70
Admissions/Month
60
50
40
30
20
Pregnancy
10
0
–2 Years
– 1 Year
Childbirth
+1 Year
Kendell RE et al. Br J Psychiatry. 1987;150:662; presented at WMH, Berlin 2001.
+2 Years
First, let us discuss the
proper terminology for
these disorders.
“Postpartum Depression”
is a general term used in
our society to describe
any psychiatric illness
occurring after childbirth.
In reality,
Postpartum Depression
describes only one of
four syndromes that can
occur after childbirth.
The four syndromes are:
• Maternity or Postpartum Blues
• Postpartum Psychosis
• Adjustment Disorder of the
Postpartum Period
• Major Depression in the Postpartum
(Postpartum Depression)
Unfortunately, common reference
to all four conditions as
“Postpartum Depression” creates
confusion and fear.
It is important to understand that
Postpartum Psychosis, the most
severe and dangerous condition,
is relatively rare and quite
different from Postpartum
Depression, as the next slide
demonstrates.
Spectrum of Postpartum
Mood Changes
Transient,
nonpathologic
Incidence
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Medical
emergency
Serious,
disabling
Postpartum Blues
risk for Postpartum
 Depression
Postpartum Depression
50% to 70%
Cohen LS. Depress Anxiety. 1998:1:18-26.
2/3 have onset by
6 wks postpartum
Postpartum Psychosis
10%
70% are affective
(Bipolar, Major
Depression)
0.01%
Postpartum Psychosis
is often mislabeled
in the media as
Postpartum Depression,
creating much anxiety
and fear in women with
the less severe
postpartum disorders.
Now, lets discuss the
specific syndromes.
Maternity or Postpartum
Blues
• Is not considered a psychiatric
illness and is unrelated to
psychiatric history .
• Occurs in 26 to 85% of birthing
mothers. The exact incidence is
unclear.
• Present in all cultures studied
• Appears unrelated to
environmental stressors
Maternity or Postpartum
Blues
“Blues” = heightened reactivity,
not clinical depression
• Mood swings from weepiness to extreme
happiness and heightened reactivity
• Occurs 3 to 5 days after childbirth. It is
self limiting, resolving in about a week.
• If occurs, increases risk for
Postpartum Depression.
The rest of
the syndromes to
be described are
all considered
psychiatric illnesses
and benefit from clinical
treatment.
Postpartum Psychosis
• Is relatively rare, occurring one to three cases
per 1000 births
• Is a severe and life threatening condition for
both mother and infant
• Develops soon after birth, often within two
weeks, usually within a month
• Requires intense treatment and
hospitalization: A medical emergency
• Is usually followed by Postpartum Depression
Symptoms of Postpartum
Psychosis
• Delusions: False beliefs, often of a
religious nature and very frequently
involving the infant
• Perceptual distortions: Seeing or
hearing things which are not present
• Often, feelings of excessive well
being or importance
Adjustment Disorder of
the Postpartum Period
• Occurs in about 20% of birthing mothers
but incidence is unclear as many women
with this problem do not seek treatment.
• Manifests as excessive difficulties
adjusting to motherhood.
• If emotional symptoms exist, they are not
as severe as those seen in Postpartum
Depression
Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Adjustment Disorder of
the Postpartum Period
• Can resolve without treatment over
time but can cause ongoing
difficulties for the mother.
• Can develop into
Postpartum Depression if more
severe and untreated.
• Responds well to
short term psychotherapy.
Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Postpartum Depression
• Occurs in 10% of birthing mothers
– 20% if the mother has had Maternity
Blues.
• Occurs usually within 6 weeks of
birth but can occur up to a year after
birth
Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Onset of Symptoms in
Postpartum Depression
Two Studies
1. Time of Onset of Postpartum Depression in 315 Women
Within 14 Days
Within 6 Weeks
46%
14%
Within 3 Months
Within 6 Months
22%
18%
2. Time of Onset of Postpartum Depression in 413 Patients
Percentage of Patients
The more severe, the earlier the onset.
60
40
Severe, needed hospital admission
Mild, treated by general practitioner
20
0 Within Two Weeks
Six Weeks
Six Months
Postpartum Depression:
Symptom Onset
• 40%: After first postnatal visit
– At 6 weeks
• 20%: Coincided with weaning
• 16%: At return of menstruation
– At 2 to 3 months if not breast feeding
• 14%: Initiation of oral contraceptives
Postpartum Depression
• Manifests as symptoms of
depression, often with marked
anxiety/agitation and obsessions
about harm coming to the child.
• Can develop gradually or
abruptly after birth
Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
What are the symptoms
of Depression?
– Sadness of mood most of the day,
nearly every day
– Diminished interest or pleasure
in usual activities
–
–
–
–
–
Major change in appetite or weight
Not able to sleep or sleeping too much
Agitation or feeling slowed down
Fatigue or loss of energy
Feelings of worthlessness or excessive or
inappropriate guilt
– Diminished ability to think or concentrate, or
indecisiveness
– Recurrent thoughts of death, dying, or suicide
APA Diagnostic and Statistical Manual. 1994
Symptoms
Frequently Seen in
Postpartum Depression
• Marked agitation and anxiety
• Mother can not sleep even when the
baby is sleeping
• Obsessions and compulsions
about the baby
What are obsessions and
compulsions?
• An obsession is a repetitive, intrusive and
disturbing thought that enters the mind
and is out of the individual's control.
• A compulsion is a repetitive act that is
done in an attempt to be rid of the
obsessional thought.
• Both cause great anxiety and discomfort
in the individual.
Postpartum obsessions
• Commonly focused on infant
• Thoughts(obsessions) of hurting the
infant
–
–
–
–
–
–
Dropping infant
Drowning infant
Stabbing infant
Putting infant in oven or microwave
Sexually abusing infant
Thoughts that someone will steal or
harm the infant
Postpartum compulsions
• Commonly follow the obsessions as an
attempt to alleviate the thought
–
–
–
–
–
–
Avoid holding baby by staircases, etc
Avoid bathing infant
Hide knives
Avoid kitchen area
Avoid changing diapers or bathing infant
Avoid leaving the house
Although the presence of
obsessions and compulsions
indicates need for treatment,
these mothers are rarely
dangerous to the infants. They are
actually at higher risk to hurt
themselves as a result of their fear
of possibly hurting the infant.
How is Postpartum
Depression treated?
• Psychiatric medication
– Antidepressants:
• In particular, those that increase release
of serotonin in the brain
– Medicines for anxiety and to
help with sleep
• Individual, couples and family
psychotherapy
What about
breast feeding?
The incidence of breast
feeding in birthing mothers
is increasing as the next
slide shows.
Incidence of Breast Feeding
1926-2001
80%
67%
61%
52%
49%
37%
28%
20%
19261930
19511955
19661970
1972
1975
1998
2000
2001
Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998
Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02
Breast feeding…
…a reasonable
option
in Postpartum
Depression ?
Although all medications
cross into breast milk,
there are a few
antidepressants that
appear to cross less than
others and may be safer
in breast feeding.
Consult your doctor.
There are risk factors that
predispose women to
postpartum disorders.
Risk Factors
•
•
•
•
•
•
•
•
First pregnancy
Young age
Psychiatric illness during pregnancy
Prior history of postpartum illness
Prior history of mental illness
Family history of mental illness
Recent stressful life events
Problems in the marriage
In addition, there are
many societal and
cultural factors that may
predispose women to
postpartum problems
including...
Isolation…
…Diminished
extended family
Involvement.
Distorted and glamorized perceptions
of pregnancy…
…and of
recovery
in the
postpartum...
…frequently
promoted
in the
media.
As well as unrealistic
expectations of the postpartum mother
In summary, postpartum
psychiatric illness exists.
It can be debilitating and
dangerous to both
mother and child.
Effective treatments are
available. Support groups of
mothers in recovery are also
available in many areas
of the country.
For more information:
• Consult with your doctor
• Contact:
– Depression-After-Delivery (DAD)
• www.DepressionAfterDelivery.com
– Depression and Bipolar Support Alliance (DBSA)
• Phone: 800-826-3632
• Web:www.DBSAlliance.org
– New Jersey Psychiatric Association
• Phone: 800-345-0143